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1.
Rabih O. Darouiche Mayar Al Mohajer Danish M. Siddiq Charles G. Minard 《Archives of physical medicine and rehabilitation》2014
Objective
To assess the applicability of a short-course regimen of antibiotics for managing catheter-associated urinary tract infection (CA-UTI) in patients with spinal cord injury (SCI).Design
Randomized, controlled, noninferiority trial.Setting
Medical center.Participants
Patients with SCI who had CA-UTI (N=61).Interventions
Patients were randomized to receive either a 5-day regimen of antibiotics after catheter exchange (experimental group) or a 10-day regimen of antibiotics with catheter retention (control group). Noninferiority was prespecified with a margin of 10%.Main Outcome Measure
Clinical cure at the end of therapy.Results
Of the 61 patients enrolled in this study, 6 patients were excluded because of bacteremia or absence of urinary symptoms. All patients (100%) achieved clinical cure at the end of therapy. The rates of microbiologic response were 82.1% in the experimental group and 88.9% in the control group (upper boundary 95% confidence interval (CI) for difference, 26%). The rates of resolution of pyuria were 89.3% in the experimental group and 88.9% in the control group (upper boundary 95% CI for difference, 16%). Patients in the experimental group had higher rates of CA-UTI recurrence than the control group. The rates of new CA-UTI, diarrhea, and Clostridium difficile colitis were similar in the 2 treatment arms.Conclusions
The primary endpoint of the study was met, indicating that the 5-day regimen with catheter exchange was noninferior to the 10-day regimen with catheter retention on the basis of clinical cure. Criteria for noninferiority on the basis of microbiologic response and resolution of pyuria were not met. 相似文献2.
Objectives
We sought to determine if the opening of an adult emergency department (ED) observation unit (OU) would impact the rate of hospital admission and ED discharges for pyelonephritis.Methods
A retrospective cohort study was performed with all adult patients from October 2003 through December 2006 in the ED meeting inclusion criteria for pyelonephritis. Clinical, demographic, and laboratory data were recorded. Primary outcomes were rates of admission, ED discharge, and return ED visits before and after the opening of our OU. We compared admission, discharge, and readmission rates using the χ2 test.Results
Nine hundred thirty charts were reviewed with 633 included for analysis. Urine cultures were performed on 420 subjects with 71% being positive. The percentage of patients admitted to a hospital inpatient unit from the ED decreased from 36% to 26% (relative risk [RR], 0.73; P = .01) after opening the OU. The percentage of patients discharged home from the ED decreased from 65% to 51% (RR, 0.76; P < .001). Among OU patients, 29% were admitted to the hospital for further inpatient care. Emergency department recidivism was unchanged by opening the OU (RR, 0.86; P = .68).Conclusions
The creation of an OU appears to influence admission decisions of ED physicians. We found that the creation of an OU significantly reduced hospital admissions for pyelonephritis but also significantly reduced ED discharges to home for pyelonephritis at our institution. 相似文献3.
Joseph M. Geskey Glenn Geeting Cheri West Christopher S. Hollenbeak 《The Journal of emergency medicine》2013
Background
Physician consultation in the Emergency Department (ED) can account for a significant portion of ED length of stay, which can lead to poor clinical outcomes.Objective
The purpose of this study was to determine whether an institutional guideline could lead to a reduction in time between consult request and admission decision. This guideline codified a 90-min expected time interval to arrive and complete an admission disposition where the consulting and admitting service were the same in an academic ED with weekly audits and reports to departmental chairs and hospital administrators.Methods
This was a study of consultation times of patients who presented to an academic ED 6 months before the adoption of an institutional guideline and 6 months after the adoption of the guideline. Data measurement in both periods included the length of time from ED consult order to admission disposition, time of ED discharge, number of ED consultations (single and multiple), ED admissions, and the hospital discharge time of admitted patients.Results
Physician consult response time decreased from 121 min to 100 min (p < 0.0001), and patients left the ED 18 min earlier (p = 0.0221) after implementation of the consultation guideline despite more ED visits, consultations, and admissions in the post-implementation time period. Patients were discharged from the inpatient setting 50 min later (p < 0.0001) after implementation of the guideline.Conclusion
An institutional guideline codifying timely ED consultations led to a significant reduction in the time from ED consultation to admission disposition while also allowing patients to leave the ED earlier in a high-occupancy academic medical center. However, the discharge time of admitted hospital patients was later after implementation of the guideline. 相似文献4.
Roberta Capp Joseph S. Ross Justin P. Fox Yongfei Wang Mayur M. Desai Arjun K. Venkatesh Harlan M. Krumholz 《The American journal of emergency medicine》2014
Background
Variation in hospital admission rates of patients presenting to the emergency department (ED) may represent an opportunity to improve practice. We seek to describe national variation in hospital admission rates from the ED and to determine the degree to which variation is not explained by patient characteristics or hospital factors.Methods
We conducted a cross-sectional analysis of a nationally representative sample of ED visits among adults within the 2010 National Hospital Ambulatory Care Survey ED data of hospitals with admission rates from the ED between 5% and 50%. We calculated risk-standardized hospital admission rates (RSARs) from the ED using contemporary hospital profiling methodology, accounting for patients' sociodemographic and clinical characteristics.Results
Among 19 831 adult ED visits in 252 hospitals, there were 4148 hospital admissions from the ED. After accounting for patients' sociodemographic and clinical factors, the median RSAR from the ED was 16.9% (interquartile range, 15.0%-20.4%), and 8.1% of the variation in RSARs was attributable to an institution-specific effect. Even after accounting for hospital teaching status, ownership, urban/rural location, and geographical location, 7.0% of the variation in RSARs from the ED was still attributable to an institution-specific effect.Conclusions and relevance
There was variation in hospital admission rates from the ED in the United States, even after adjusting for patients' sociodemographic and clinical characteristics and accounting for hospital factors. Our findings suggest that suggesting that the likelihood of being admitted from the ED is not only dependent on clinical factors but also at which hospital the patient seeks care. 相似文献5.
Sean P. Collins Daniel P. Schauer Amit Gupta Hermine Brunner Alan B. Storrow Mark H. Eckman 《The American journal of emergency medicine》2009
Background
The ED disposition of patients with non–high-risk acute decompensated heart failure (ADHF) is challenging. To help address this problem, we investigated the cost-effectiveness of different ED disposition strategies.Methods
We constructed a decision analytic model evaluating the cost-effectiveness of 3 possible ED ADHF disposition strategies in a 60-year-old man: (1) discharge home from the ED; (2) observation unit (OU) admission; (3) inpatient admission. Base case patients had no high-risk features. We used Medicare costs and the national physician fee schedule to capture ED, OU, and hospital costs, including costs of complications and death. All analyses were conducted using Decision Maker software (University of Medicine and Dentistry of New Jersey, Newark, NJ).Results
Compared to ED discharge, OU admission had a reasonable marginal cost-effectiveness ratio ($44 249/quality adjusted life year), whereas hospital admission had an unacceptably high marginal cost-effectiveness ratio ($684 101/quality adjusted life year). Sensitivity analyses demonstrated that as the risk of early (within 5 days) and late (within 30 days) readmission exceeded 36% and 74%, respectively, in those discharged from the ED, OU admission became less costly and more effective than ED discharge. Similarly, an increase in relative risk of both early and late death in those discharged from the ED improves the marginal cost-effectiveness ratio of OU admission. Finally, as postdischarge event rates increase in those discharged from the OU, hospital admission became more cost-effective.Conclusion
Observation unit admission for patients with non–high-risk ADHF has a societally acceptable marginal cost-effectiveness ratio compared to ED discharge. However, as ED and OU discharge event rates increase, hospital admission becomes the more cost-effective strategy. 相似文献6.
Scott D. Cline MD Robyn A.K. Schertz MD Eric C. Feucht MD 《The American journal of emergency medicine》2009,27(7):843-846
Background
To determine if expedited admission (<2 hours) of critically ill patients requiring intubation and mechanical ventilation from the emergency department (ED) to the intensive care unit (ICU) decreases ICU and hospital length of stay.Methods
Patients with respiratory failure that required intubation and mechanical ventilation who were admitted to the hospital between June 2004 and May 2006 were retrospectively identified from the Project IMPACT database. Patients were divided into 2 groups based on ED length of stay: expedited (<2 hours) or nonexpedited (>2 hours).Results
The expedited (n = 12) and nonexpedited (n = 66) groups were comparable in demographics, medical conditions, and disease severity. Mean duration of mechanical ventilation was significantly shorter in the expedited group (28.4 hours vs 67.9 hours; P = .0431), as was mean ICU length of stay (2.4 days vs 4.9 days; P = .0209). Length of hospital stay tended to be shorter for the patients in the expedited group (6.8 days vs 8.9 days; P = .0609).Conclusions
Expedited admission (<2 hours) of critically ill patients requiring intubation and mechanical ventilation from the ED to the ICU was associated with shorter durations of mechanical ventilation and ICU length of stay, suggesting that prompt ICU admission results in improved use of resources. 相似文献7.
Nicholas J. Johnson Rama A. Salhi Benjamin S. Abella Robert W. Neumar David F. Gaieski Brendan G. Carr 《Resuscitation》2013
Background
Sudden cardiac arrest (SCA) is a leading cause of death in the US. Recent innovations in post-arrest care have been demonstrated to increase survival. However, little is known about the impact of emergency department (ED) and hospital characteristics on survival to hospital admission and ultimate outcome.Objective
We sought to describe the incidence of SCA presenting to the ED and to identify ED and hospital characteristics associated with survival to hospital admission.Methods
We identified patients with diagnoses of atraumatic cardiac arrest or ventricular fibrillation (ICD-9 427.5 or 427.41) in the 2007 Nationwide Emergency Department Sample (NEDS), a nationally representative estimate of all ED admissions in the United States. We defined SCA as cardiac arrest in the out-of-hospital or ED settings. We used the NEDS sample design to generate nationally representative estimates of the incidence of SCA that presents to EDs. We performed unadjusted and adjusted analyses to examine the relation between patient, ED, and hospital characteristics and outcome using logistic regression. Our primary outcome was survival to hospital admission. Survival to hospital discharge was a secondary outcome. Data are presented as odds ratios (OR) with 95% confidence intervals (CI).Results
Of the 966 hospitals in the NEDS, 933 (96.6%) reported at least one SCA and were included in the analysis. We identified 38,593 cases of cardiac arrest representing an estimated 174,982 cases nationally. Overall ED SCA survival to hospital admission was 26.2% and survival to discharge was 15.7%. Greater survival to admission was seen in teaching hospitals (OR 1.3 95% CI 1.1–1.5, p = 0.001), hospitals with ≥20,000 annual ED visits (OR 1.3 95% CI 1.1–1.6, p = 0.003), and hospitals with percutaneous coronary intervention capability (OR 1.6 95% CI 1.4–1.8, p < 0.001). Higher SCA volume (>40 annually) was associated with lower survival overall (OR 0.7 95% 0.6–0.9, p = 0.010), but not when transferred patients were excluded from the analysis (OR 0.8 95% CI 0.6–1.1, p = 0.116).Conclusions
An estimated 175,000 cases of SCA present to or occur in US EDs each year. Percutaneous coronary intervention capability, ED volume, and teaching status were associated with higher survival to hospital admission. Emergency departments with higher annual SCA volume had lower survival rates, possibly because they transfer fewer patients. An improved understanding of the contribution of ED care to survival following SCA may be useful in advancing our understanding of how best to organize a system of care to ensure optimal outcomes for patients with SCA. 相似文献8.
Birkhahn RH Wen W Datillo PA Briggs WM Parekh A Arkun A Byrd B Gaeta TJ 《The Journal of emergency medicine》2012,43(2):356-365
Background
The current paradigm for the evaluation of patients with suspected acute coronary syndromes (ACS) in the emergency department (ED) is focused on the identification of patients with active underlying coronary disease. The majority of patients evaluated in the ED setting do not have active underlying cardiac disease.Objective
To measure the effect of bedside point-of-care (POC) cardiac biomarker testing on telemetry unit admissions from the ED. Furthermore, to evaluate the effect telemetry admissions have on ED length of stay (LOS) and overall hospital LOS.Methods
Primary data were collected over two 6-month periods in an urban teaching hospital ED. This was an observational cohort study conducted pre- and post- availability of a POC testing platform for cardiac biomarkers. Major measures included number of overall telemetry admissions, ED LOS, hospital LOS, and disposition. Patients were followed at 30 days for significant cardiac events, repeat ED visit or admission, and death.Results
In the post-implementation period there was a 30% (95% confidence interval [CI] 36–44%) reduction in admissions to telemetry with a 33% (95% CI 26–39%) reduction in ED LOS and a 20% (95% CI 7–34%) reduction in hospital LOS. There was a 62% reduction in overall mortality between the pre-implementation period and the post-implementation period (p = 0.001).Conclusion
The focused use of a rapid cardiac disposition protocol can dramatically impact resource utilization, expedite patient flow, and improve short-term outcomes for patients with suspected ACS. 相似文献9.
Walraven CJ Lingenfelter E Rollo J Madsen T Alexander DP 《The Journal of emergency medicine》2012,42(4):392-399
Background
Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections commonly present as skin and soft-tissue infections (SSTIs). Treatment often includes incision and drainage with or without adjunctive antibiotics. Emergency department (ED) pharmacists wished to provide specific data to emergency physicians to better inform antibiotic choices for patients with SSTIs.Study Objectives
The objectives of this study were to describe local susceptibility trends of CA-MRSA isolates obtained from patients with SSTIs and describe diagnostic and empiric therapeutic management of CA-MRSA SSTIs among ED health care providers at University of Utah Hospitals and Clinics.Methods
Susceptibility of all unique CA-MRSA SSTI isolates for 2008 were identified and compiled into an antibiogram. ED providers evaluated their diagnostic and treatment habits using a self-assessment questionnaire, which was verified against charted information documented in the electronic medical records for patients presenting to the ED with a CA-MRSA SSTI.Results
The ED antibiogram indicated that 57/58 (98%) CA-MRSA SSTI isolates were susceptible to sulfamethoxazole/trimethoprim (SMX/TMP); 50/58 (86%) isolates were susceptible to tetracycline, and 47/58 (81%) isolates were susceptible to clindamycin. Incision and drainage were performed in 23/25 (92%) patient cases, which was consistent with providers’ perceived habits (100%). SMX/TMP monotherapy was preferred among 23/35 (66%) providers, however, SMX/TMP combined with cephalexin was the antibiotic regimen prescribed in 9/22 (41%) patient cases.Conclusions
Cephalexin was often added to cover for potential cellulitis due to Streptococcus spp., however, the surrounding erythema may simply be an extension of the CA-MRSA infection. Department-specific antibiograms are useful in guiding empiric antibiotic selection and may help providers judiciously prescribe antibiotics only when necessary. 相似文献10.
Folafoluwa O. Odetola MD MPH Sarah J. Clark MPH James G. Gurney PhD Ronald E. Dechert DrPH Thomas P. Shanley MD FCCM Gary L. Freed MD MPH 《Journal of critical care》2009,24(3):379-386
Purpose
The study aimed to examine the effect of interhospital transfer on resource utilization and clinical outcomes at a tertiary pediatric intensive care unit (PICU) among patients with sepsis or respiratory failure.Materials and methods
Data on 2146 consecutive admissions with respiratory failure or sepsis to the PICU were analyzed. Data included demographics, admission source, and outcomes. Admission source was classified as interhospital transfer from the emergency departments (ED), wards, or PICUs of referring hospitals; or from the study hospital ED (direct).Results
Compared with direct admissions, inter-PICU transfers had higher crude mortality (odds ratio, 1.93; 95% confidence interval, 1.31-2.84) but not significant mortality difference (odds ratio, 1.16; 95% confidence interval, 0.71-1.86) after adjusting for illness severity, age, and sex. Conversely, ED transfers had lower PICU mortality than direct ED admissions. Children with transfer admissions stayed significantly longer and used more intensive care technology in the study PICU than children directly admitted (P < .01). In comparisons within quartiles of mortality risk, inter-PICU transfers had longer hospitalization and higher mortality in all but the highest quartile.Conclusions
Interhospital transfer, particularly inter-PICU transfer, was associated with significant hospital resource consumption that often correlated with admission illness severity. Future prospective studies should identify determinants of pretransfer illness severity and investigate decision making underlying interhospital transfer. 相似文献11.
Powell ES Khare RK Courtney DM Feinglass J 《The American journal of emergency medicine》2012,30(3):432-439
Purpose
Early aggressive resuscitation in patients with severe sepsis decreases mortality but requires extensive time and resources. This study analyzes if patients with sepsis admitted through the emergency department (ED) have lower inpatient mortality than do patients admitted directly to the hospital.Procedures
We performed a cross-sectional analysis of hospitalizations with a principal diagnosis of sepsis in institutions with an annual minimum of 25 ED and 25 direct admissions for sepsis, using data from the 2008 Nationwide Inpatient Sample. Analyses were controlled for patient and hospital characteristics and examined the likelihood of either early (2-day postadmission) or overall inpatient mortality.Findings
Of 98?896 hospitalizations with a principal diagnosis of sepsis, from 290 hospitals, 80,301 were admitted through the ED and 18?595 directly to the hospital. Overall sepsis inpatient mortality was 17.1% for ED admissions and 19.7% for direct admissions (P < .001). Overall early sepsis mortality was 6.9%: 6.8% for ED admissions and 7.4% for direct admissions (P = .005). Emergency department patients had a greater proportion of comorbid conditions, were more likely to have Medicaid or be uninsured (12.5% vs 8.4%; P < .001), and were more likely to be admitted to urban, large bed-size, or teaching hospitals (P < .001). The risk-adjusted odds ratio for overall mortality for ED admissions was 0.83 (95% confidence interval, 0.80-0.87) and 0.92 for early mortality (95% confidence interval, 0.86-0.98), as compared with direct admissions to the hospital.Conclusion
Admission for sepsis through the ED was associated with lower early and overall inpatient mortality in this large national sample. 相似文献12.
13.
Jonathan Rosenson Carter Clements Barry Simon Jules Vieaux Sarah Graffman Farnaz Vahidnia Bitou Cisse Joseph Lam Harrison Alter 《The Journal of emergency medicine》2013
Background
Acute alcohol withdrawal syndrome (AAWS) is encountered in patients presenting acutely to the Emergency Department (ED) and often requires pharmacologic management.Objective
We investigated whether a single dose of intravenous (i.v.) phenobarbital combined with a standardized lorazepam-based alcohol withdrawal protocol decreases intensive care unit (ICU) admission in ED patients with acute alcohol withdrawal.Methods
This was a prospective, randomized, double-blind, placebo-controlled study. Patients were randomized to receive either a single dose of i.v. phenobarbital (10 mg/kg in 100 mL normal saline) or placebo (100 mL normal saline). All patients were placed on the institutional symptom-guided lorazepam-based alcohol withdrawal protocol. The primary outcome was initial level of hospital admission (ICU vs. telemetry vs. floor ward).Results
There were 198 patients enrolled in the study, and 102 met inclusion criteria for analysis. Fifty-one patients received phenobarbital and 51 received placebo. Baseline characteristics and severity were similar in both groups. Patients that received phenobarbital had fewer ICU admissions (8% vs. 25%, 95% confidence interval 4–32). There were no differences in adverse events.Conclusions
A single dose of i.v. phenobarbital combined with a symptom-guided lorazepam-based alcohol withdrawal protocol resulted in decreased ICU admission and did not cause increased adverse outcomes. 相似文献14.
Daniela Dicu Felicia Pop Daniela Ionescu Tiberius Dicu 《The American journal of emergency medicine》2013
Background
Admission Rockall score (RS), full RS, and Glasgow-Blatchford Bleeding Score (GBS) can all be used to stratify the risk in patients presenting with upper gastrointestinal bleeding (UGIB) in the emergency department (ED). The aim of our study was to compare both admission and full RS and GBS in predicting outcomes at UGIB patients in a Romanian ED.Patients and Methods
A total of 229 consecutive patients with UGIB were enrolled in the study. Patients were followed up 60 days after admission to ED because of UGIB episode to determine cases of rebleeding or death during this period. By using areas under the curve (AUCs), we compared the 3 scores in terms of identifying the most predictive score of unfavorable outcomes.Results
Rebleeding rate was 40.2% (92 patients), and mortality rate was 18.7% (43 patients). For the prediction of mortality, full RS was superior to GBS (AUC, 0.825 vs 0.723; P = .05) and similar to admission RS (AUC, 0.792). Glasgow-Blatchford Bleeding Score had the highest accuracy in detecting patients who needed transfusion (AUC, 0.888) and was superior to both the admission RS and full RS (AUC, 0.693 and 0.750, respectively) (P < .0001). In predicting the need for intervention, the GBS was superior to both the admission RS and full RS (AUC, 0.868, 0.674, and 0.785, respectively) (P < .0001 and P = .04, respectively).Conclusions
The GBS can be used to predict need for intervention and transfusion in patients with UGIB in our ED, whereas full RS can be successfully used to stratify the mortality risk in these patients. 相似文献15.
Christopher W. Jones Seema S. Sonnad James J. Augustine Charles L. Reese IV 《The American journal of emergency medicine》2014
Background
Performance of percutaneous coronary intervention (PCI) within 90 minutes of hospital arrival for ST-segment elevation myocardial infarction patients is a commonly cited clinical quality measure. The Centers for Medicare and Medicaid Services use this measure to adjust hospital reimbursement via the Value-Based Purchasing Program. This study investigated the relationship between hospital performance on this quality measure and emergency department (ED) operational efficiency.Methods
Hospital-level data from Centers for Medicare and Medicaid Services on PCI quality measure performance was linked to information on operational performance from 272 US EDs obtained from the Emergency Department Benchmarking Alliance annual operations survey. Standard metrics of ED size, acuity, and efficiency were compared across hospitals grouped by performance on the door-to-balloon time quality measure.Results
Mean hospital performance on the 90-minute arrival to PCI measure was 94.0% (range, 42-100). Among hospitals failing to achieve the door-to-balloon time performance standard, median ED length of stay was 209 minutes, compared with 173 minutes among those hospitals meeting the benchmark standard (P < .001). Similarly, median time from ED patient arrival to physician evaluation was 39 minutes for hospitals below the performance standard and 23 minutes for hospitals at the benchmark standard (P < .001). Markers of ED size and acuity, including annual patient volume, admission rate, and the percentage of patients arriving via ambulance did not vary with door-to-balloon time.Conclusion
Better performance on measures associated with ED efficiency is associated with more timely PCI performance. 相似文献16.
Hitti EA Lewin JJ Lopez J Hansen J Pipkin M Itani T Gurny P 《The Journal of emergency medicine》2012,42(4):462-469
Background
The Surviving Sepsis Campaign (SSC) guidelines recommend that broad-spectrum antibiotics be administered to severely septic patients within 3 h of emergency department (ED) admission. Despite the well-established evidence regarding the benefit of timely antibiotics, adoption of the SSC recommendation into daily clinical practice has been slow and sporadic.Study Objective
To study the impact of storing broad-spectrum antibiotics in an ED automated dispensing cabinet (ADC) on the timeliness of antibiotic administration in severely septic patients presenting to the ED.Methods
Retrospective observational study of timeliness of antibiotic administration in severely septic patients presenting to a community ED before and after adding broad-spectrum antibiotics to the ED ADC. Data on 56 patients before and 54 patients after the intervention were analyzed. The primary outcome measure was mean order-to-antibiotic time. Secondary outcome measures included mean door-to-antibiotic time and percentage of patients receiving antibiotics within 3 h.Results
The final analysis was on 110 patients. Order-to-antibiotic administration time was reduced by 29 min post-intervention (55 min vs. 26 min, 95% confidence interval [CI] 12.5–45.19). Mean door-to-antibiotic time was also reduced by 70 min (167 min vs. 97 min, 95% CI 37.53–102.29). The percentage of severely septic patients receiving antibiotics within 3 h of arrival to the ED increased from 65% pre-intervention to 93% post-intervention (95% CI 0.12–0.42).Conclusion
Storing key antibiotics in an institution’s severe sepsis antibiogram in the ED ADC can significantly reduce order-to-antibiotic times and increase the percentage of patients receiving antibiotics within the recommended 3 h of ED arrival. 相似文献17.
Rationale
Emergency department (ED) patients in need of an intensive care unit (ICU) admission are very sick. Reducing the length of time to get these patients into ICU beds is associated with improved outcomes.Objective
To reduce the ED length of stay for patients requiring admission to the medical ICU or coronary care unit through the implementation of the “active bed management” (ABM) intervention.Methods
A pre-post study design compared data from November 2006 to February 2007 with those from those same months in the prior year at Johns Hopkins Bayview Medical Center in Baltimore. The ABM intervention was carried out by hospitalist physicians and involved: (i) making triage decisions for patients to be admitted and facilitating their transfer from ED to the appropriate care setting and (ii) having proactive management of Department of Medicine resources, which included twice-daily ICU bed management rounds and regular visits to the ED to assess flow.Measurement
Throughput time for patients presenting to the ED requiring ICU admission was analyzed.Main Results
The ED census was higher during the intervention period as compared with the control period, 17?573 versus 16?148 patients. Throughput from ED to coronary care unit and medical ICU beds was reduced by 99 (±14) minutes (from 353 minutes in the control period to 254 minutes in the 4 months after the initiation of ABM, P < .0001). Staffing, length of stay, case mix index, ICU transfer rates, and ICU death rates were stable across the 2 periods, all P = not significant.Conclusion
Conscientious management of hospital beds, in this case by hospitalist physicians providing ABM, can have a positive and substantial impact on the ED throughput of critically ill patients admitted to ICU beds. This efficiency is likely to positively have impacted on patient satisfaction and safety. 相似文献18.
Jeffrey M. Caterino MD MPH Emily M. HooverMark G. Moseley MD 《The American journal of emergency medicine》2013
Objectives
The primary objective was to determine the relationship between advanced age and need for admission from an emergency department (ED) observation unit. The secondary objective was to determine the relationship between initial ED vital signs and admission.Methods
We conducted a prospective, observational cohort study of ED patients placed in an ED-basedobservation unit. Multivariable penalized maximum likelihood logistic regression was used to identify independent predictors of need for hospital admission. Age was examined continuously and at acutoff of 65 years or more. Vital signs were examined continuously and at commonly accepted cutoffs.We additionally controlled for demographics, comorbid conditions, laboratory values, and observation protocol.Results
Three hundred patients were enrolled, 12% (n = 35) were 65 years or older, and 11% (n = 33) required admission. Admission rates were 2.9% (95% confidence interval [CI], 0.07%-14.9%) in older adults and 12.1% (95% CI, 8.4%-16.6%) in younger adults. In multivariable analysis, age was not associated with admission (odds ratio [OR], 0.30; 95% CI, 0.05-1.67). Predictors of admission included systolic pressure 180 mm Hg or greater (OR, 4.19; 95% CI, 1.08-16.30), log Charlson comorbidity score (OR, 2.93; 95% CI, 1.57-5.46), and white blood cell count 14?000/mm3 or greater (OR, 11.35; 95% CI, 3.42-37.72).Conclusions
Among patients placed in an ED observation unit, age 65 years or more is not associated with need for admission. Older adults can successfully be discharged from these units. Systolic pressure 180 mm Hg or greater was the only predictive vital sign. In determining appropriateness of patients selected for an ED observation unit, advanced age should not be an automatic disqualifying criterion. 相似文献19.
Kathryn A. Volz Louisa CanhamEmily Kaplan MD Leon D. SanchezNathan I. Shapiro MD MPH Shamai A. Grossman MD 《The American journal of emergency medicine》2013
Background
Emergency department observation units (EDOU) are often used for patients with cellulitis to provide intravenous antibiotics followed by a transition to an oral regimen for discharge. Because institutional regulations typically limit EDOU stays to 24 hours, patients lacking a clinical response within this period will often be subsequently admitted to the hospital for further treatment.Objective
The aim of this study was to determine the rate of hospital admission and characteristics predictive of admission in patients with cellulitis who are initially placed in an ED observation unit.Methods
A retrospective cohort study of patients placed into EDOU with a diagnosis of skin infection was conducted. Age, sex, history of diabetes mellitus, immunosuppression, intravenous drug use, location of cellulitis, presence of abscess, laboratory infectious markers, vital signs, and outpatient antibiotic treatment were recorded. The primary outcome was a hospital admission due to failure to respond to treatment within the 24-hour observation time window. Significant variables on univariate analysis were used to create a multivariate analysis, which identified predictive characteristics.Results
Four hundred six patient charts were reviewed, with 377 meeting inclusion criteria; the inpatient admission rate from EDOU was 29.2%. Using logistic regression techniques, we created a model of independent predictors for need of admission after 24 hours: cellulitis of the hand (odds ratio [OR], 2.9; 95% confidence interval [CI], 1.8-4.9), measured temperature higher than 100.4°F (OR, 2.5; 95% CI, 1.1-5.5), and lactate greater than 2 (OR, 3.1; 95% CI, 1.3-7.3) were predictive of failure of ED observation.Conclusions
Patients with cellulitis placed into ED observation status were more likely to fail an observation trial if they had an objective fever in the ED, an elevated lactate, or a cellulitis that involved the hand. 相似文献20.
Sion Jo Taeoh Jeong Jae Baek Lee Young Ho Jin Jaechol Yoon Yong Kyu Jun Boyoung Park 《The American journal of emergency medicine》2012